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4. Access to Primary Care: Avoidable Hospital Conditions
- Johns Hopkins University Press
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74 chapter four Access to Primary Care Avoidable Hospital Conditions Avoidable mortality is a useful summary measure of health system performance, reflecting a range of health care interventions, from primary and secondary prevention to tertiary care. Its breadth is both a strength and weakness. An exclusive focus on avoidable deaths, however, does not identify the contributions of public health, primary health care, or specialty medical services. In this chapter, we refine our analysis of access to care by comparing hospital discharge rates for avoidable hospital conditions (AHCs) across and within the three cities. AHCs are inpatient hospitalizations for a host of conditions that, in theory, can be “avoided” through timely access to effective primary health care. These include hospitalizations for bacterial pneumonia, cellulitis, and several chronic conditions, such as congestive heart failure, asthma, and diabetes . It is not possible to eliminate all hospitalizations for most of these conditions, but access to primary care for their effective management should significantly reduce the number of acute episodes leading to hospitalization. AHC is widely accepted as a valid measure of access to primary care. In its 1993 report Access to Health Care in America (Millman, 1993), the Institute of Medicine recommended that AHC rates be used to monitor access to health care services at the national level and that these rates be tracked over time to determine whether conditions for obtaining care were improving or deteriorating, especially for vulnerable populations. Since then, the Agency for Healthcare Research and Quality (AHRQ) has used AHCs to monitor access to safety net services across large metropolitan areas of the nation (Billings, 2004), and the Commonwealth Fund is publishing annual state-wide comparisons based on Medicare data (Cantor et al., 2007). Access to Primary Care 75 Because many of these hospitalizations are for chronic conditions, comparing AHC rates also provides important information about how well health care systems are coping with the growing challenge of chronic disease (Ettelt et al., 2006; Olshansky et al., 2005). As the populations in these cities grow older, an increasing number of adults have multiple chronic conditions. If their care is not well coordinated, such adults are at risk for avoidable hospitalizations and other adverse events (Davis, 2007). To provide a broader context for our comparison of AHCs across and within our three cities, we begin with some background on the management of chronic disease and the challenge of comparing primary care systems. Managing Chronic Disease Four chronic diseases—cancer,cardiovascular disease,diabetes,and chronic lung diseases—are responsible for at least half of all deaths in the world each year (Suhrcke et al., 2006). Other estimates suggest that “more than four-fifths of all deaths and two-fifths of all disabilities” can be attributed to these four diseases—and nearly half of these deaths are premature (Stuckler, 2008: 276). One estimate in the United States suggests that the care of chronic disease accounts for 78 percent of national health expenditures (Anderson and Horvath, 2002). Over the past decade, the incidence of diabetes worldwide has nearly doubled (International Diabetes Federation, 2006). Current projections suggest that by 2020, one-tenth of the world’s population will have diabetes (Suhrcke et al., 2006). Increases in diabetes and other chronic diseases threaten to curb the gains in longevity achieved over the past 30 years, not to mention quality of life (Olshansky et al.,2005),and contribute to rising health care costs (Thorpe and Howard, 2006). Moreover, the growth of chronic disease is most relevant for the study of health systems in world cities because globalization and urbanization are often cited as factors contributing to its growth (Stuckler, 2008). Because the care of people with chronic conditions accounts for a disproportionate share of health expenditures, policy makers across the world are struggling to improve coordination of health services for patients with chronic conditions. For example, interest in disease management and primary care gatekeeping has grown in Europe since the late [3.230.1.23] Project MUSE (2024-03-29 00:43 GMT) 76 Health Care in World Cities 1990s. In 2004, France enacted a health care reform plan under the leadership of health minister Philippe Douste-Blazy.The most important feature of the law was to promote the development and application of managed care techniques, including computerized medical records, practice guidelines , and incentives to encourage primary care physicians to coordinate health services for their patients. At present, more than 85 percent of the French population has signed up with a médecin traitant (primary care physician...